From Pregnancy Pains to Paralysis: An Erroneous Intrathecal Digoxin Administration Case Report and Review of Medical Errors

Digoxin is a Na-K ATPase inhibitor commonly used to treat heart failure and atrial fibrillation. It is only approved for oral or intravenous (IV) use. There is no approved indication for intrathecal administration. Only four previously reported cases of intrathecal digoxin administration in pregnant patients are in the literature. We present a patient who had an unfortunate case of erroneous intrathecal Digoxin administration following an elective Cesarean section. Post-delivery, the patient's mental status deteriorated. She became unresponsive and remained comatose for 11 days. Brain magnetic resonance imaging (MRI) showed diffuse, patchy hyperintensities involving bilateral frontotemporal lobes and basal ganglia. A spine MRI showed extensive cervical and thoracic cord edema. At discharge, the patient was paraplegic with no sensation or motor response below the level of T10. At the 90-day follow-up, she had intact mental status and minimal improvement in motor strength and sensation below T10 and was reportedly breastfeeding. This is an unfortunate case of severe neurological deficits resulting from a grave medical error, which continues to be a prevalent issue in the United States healthcare system.